Does Preoperative Calcium and Calcitriol Decrease Rates of Post-Thyroidectomy Hypocalcemia? A Randomized Clinical Trial.

BACKGROUND: Postoperative hypocalcemia is the most common complication after thyroidectomy. Postoperative supplementation with calcium and calcitriol reduces its occurrence; however, prophylactic preoperative supplementation has not been studied systematically. The primary objective of this study was to determine whether pre- and postoperative calcium and calcitriol supplementation reduces postoperative hypocalcemia after total thyroidectomy compared with postoperative supplementation alone. STUDY DESIGN: We conducted a single-institution prospective randomized trial enrolling 82 patients undergoing total thyroidectomy from July 2017 through May 2019. Those undergoing partial thyroidectomy or concurrent planned parathyroidectomy were excluded. The intervention group started calcitriol 0.25 µg po bid and calcium carbonate 1,500 mg po tid 5 days preoperatively and continued postoperatively. The control group started these medications postoperatively. The primary end point was clinical or biochemical hypocalcemia. Secondary outcomes were postoperative calcium levels, need for intervention, length of stay, and readmission. RESULTS: Thirty-eight patients were randomized to the intervention group and 44 to the control group. There were 12 episodes of hypocalcemia; 5 (13.2%) in the intervention and 7 (15.9%) in the control group (p = 0.76). No differences were found in secondary outcomes; including postoperative calcium levels at each measured time point, need for intervention (n = 10 [26.3%], n = 15 [34.1%]; p = 0.48), length of stay (mean [SD] 32.3 [15.6] hours, 30.7 [10.5] hours; p = 0.6), or readmissions (n = 0 [0.0%], n = 3 [6.8%]; p = 0.24). CONCLUSIONS: Starting supplementation with calcium and calcitriol preoperatively does not reduce postoperative hypocalcemia compared with postoperative supplementation alone after total thyroidectomy. These findings do not support the practice of routine calcium and calcitriol supplementation before total thyroidectomy.

The Impact of MassPAT on Opioid Prescribing Patterns for Otolaryngology Surgeries.

OBJECTIVE: Determine whether opioid prescriber patterns have changed for tonsillectomy, parotidectomy, and thyroidectomy after implementation of the Massachusetts Prescription Awareness Tool (MassPAT). STUDY DESIGN: Retrospective cohort study. SETTING: Single-center tertiary care hospital. METHODS: Patients were included if they received tonsillectomy, parotidectomy, or thyroid surgery at Lahey Hospital and Medical Center (Burlington, Massachusetts) between October 1, 2015, and October 1, 2019. Prescribing patterns were compared prior to implementation of MassPAT, October 1, 2015, to October 14, 2016, to postimplementation of MassPAT, October 15, 2016, to October 1, 2019. Quantity of opioids prescribed was described using total morphine milligram equivalents (MME). Data were analyzed using univariate analysis, multivariate analysis, and trend line using line of best fit. RESULTS: A total of 737 subjects were included in the study. There was a downward trend in the quantity of opioids prescribed for all 3 surgeries during the study period. There was a significant difference in the quantity of opioids prescribed pre- and postimplementation of MassPAT for tonsillectomy (647.70 ± 218.50 MME vs 474.60 ± 185.90 MME, P < .001), parotidectomy (241.20 ± 57.66 MME vs 156.70 ± 72.99 MME, P < .001), and thyroidectomy (171.20 ± 93.77 MME vs 108.50 ± 63.84 MME, P < .001). There was also a decrease in the number of patients who did not receive opioids for thyroidectomy pre- and post-MassPAT (7.56% vs 24.14%). CONCLUSION: We have demonstrated that there is an association with state drug monitoring programs and decrease in the amount of opioids prescribed for acute postoperative pain control for common otolaryngology surgeries.

Highly specific preoperative selection of solitary parathyroid adenoma cases in primary hyperparathyroidism by quantitative image analysis of the early-phase Technetium-99m sestamibi scan.

INTRODUCTION: Highly specific preoperative localizing test is required to select patients for minimally invasive parathyroidectomy (MIP) in lieu of traditional four-gland exploration. We hypothesized that Tc-99m sestamibi scan interpretation incorporating numerical measurements on the degree of asymmetrical activity from bilateral thyroid beds can be useful in localizing single adenoma for MIP. METHODS: We devised a quantitative interpretation method for Tc-99m sestamibi scan based on the numerically graded asymmetrical activity on early phase. The numerical ratio value of each scan was obtained by dividing the number of counts from symmetrically drawn regions of interest (ROI) over bilateral thyroid beds. The final pathology and clinical outcome of 109 patients were used to perform receiver operating curve (ROC) analysis. RESULTS: Receiver operating curve analysis revealed the area under the curve (AUC) was calculated to be 0.71 (P = 0.0032), validating this method as a diagnostic tool. The optimal cut-off point for the ratio value with maximal combined sensitivity and specificity was found with corresponding sensitivity of 67.9% (56.5-77.2%, 95% CI) and specificity of 75.0% (52.8-91.8%, 95% CI). An additional higher cut-off with higher specificity with minimal possible sacrifice on sensitivity was also selected, yielding sensitivity of 28.6% (18.8-38.6%, 95% CI) and specificity of 90.0% (69.6-98.8%, 95% CI). CONCLUSIONS: Our results demonstrated that the more asymmetrical activity on the initial phase, the more successful it is to localize a single parathyroid adenoma on sestamibi scans. Using early-phase Tc-99m sestamibi scan only, we were able to select patients for minimally invasive parathyroidectomy with 90% specificity.

Long-Term Patient-Reported Outcomes of Paraesophageal Hernia Repair.

BACKGROUND AND OBJECTIVES: There is a lack of consensus on the optimal repair technique and the definition of good outcomes in paraesophageal hernia (PEH) repair. We reviewed long-term patient-reported outcomes of open and laparoscopic PEH repair to assist with our future surgical consent process. METHODS: This was a retrospective case-control study including all patients with PEH repair performed from 2000 through 2012 at a single center without the use of mesh. We mailed questionnaires to patients to assess reoperation, symptom control, and satisfaction. RESULTS: Chart review identified 217 patients who underwent PEH repair. Nineteen died during the follow-up period. Of the 106 returning the questionnaire, 87 underwent laparoscopic repair, and 19 had open repair, with follow-up of 6.6 (SD 3.9) years and 7.0 (SD 4.1) years, respectively. Reoperation rates were 9.9% and 5.3%, respectively (P = .720). Dysphagia, heartburn, and regurgitation improved in 95.4% of patients after laparoscopic repair and 89.5% after open repair (P = .318). Medication for symptom control was necessary in 54.0% of patients after laparoscopic repair and 26.3% after open repair (P = .029). In each group, 90% stated that they would still choose to have the operation (P = .713). CONCLUSIONS: Long-term patient-specific outcomes showed comparable, encouraging results between open and laparoscopic repair of PEH without mesh reinforcement. However, half of those undergoing laparoscopic repair required the use of medication for symptom control. This study adds to the literature describing long-term patient-specific outcomes and can be useful when counseling patients about PEH repair.

Effect of Incentive Spirometry on Postoperative Hypoxemia and Pulmonary Complications After Bariatric Surgery: A Randomized Clinical Trial.

Importance: The combination of obesity and foregut surgery puts patients undergoing bariatric surgery at high risk for postoperative pulmonary complications. Postoperative incentive spirometry (IS) is a ubiquitous practice; however, little evidence exists on its effectiveness. Objective: To determine the effect of postoperative IS on hypoxemia, arterial oxygen saturation (Sao2) level, and pulmonary complications after bariatric surgery. Design, Setting, and Participants: A randomized noninferiority clinical trial enrolled patients undergoing bariatric surgery from May 1, 2015, to June 30, 2016. Patients were randomized to postoperative IS (control group) or clinical observation (test group) at a single-center tertiary referral teaching hospital. Analysis was based on the evaluable population. Interventions: The controls received the standard of care with IS use 10 times every hour while awake. The test group did not receive an IS device or these orders. Main Outcomes and Measures: The primary outcome was frequency of hypoxemia, defined as an Sao2 level of less than 92% without supplementation at 6, 12, and 24 postoperative hours. Secondary outcomes were Sao2 levels at these times and the rate of 30-day postoperative pulmonary complications. Results: A total of 224 patients (50 men [22.3%] and 174 women [77.7%]; mean [SD] age, 45.6 [11.8] years) were enrolled, and 112 were randomized for each group. Baseline characteristics of the groups were similar. No significant differences in frequency of postoperative hypoxemia between the control and test groups were found at 6 (11.9% vs 10.4%; P = .72), 12 (5.4% vs 8.2%; P = .40), or 24 (3.7% vs 4.6%; P = .73) postoperative hours. No significant differences were observed in mean (SD) Sao2 level between the control and test groups at 6 (94.9% [3.2%] vs 94.9% [2.9%]; P = .99), 12 (95.4% [2.2%] vs 95.1% [2.5%]; P = .40), or 24 (95.7% [2.4%] vs 95.6% [2.4%]; P = .69) postoperative hours. Rates of 30-day postoperative pulmonary complications did not differ between groups (8 patients [7.1%] in the control group vs 4 [3.6%] in the test group; P = .24). Conclusions and Relevance: Postoperative IS did not demonstrate any effect on postoperative hypoxemia, Sao2 level, or postoperative pulmonary complications. Based on these findings, the routine use of IS is not recommended after bariatric surgery in its current implementation. Trial Registration: clinicaltrials.gov Identifier: NCT02431455.

Sleep apnea: is routine preoperative screening necessary?

BACKGROUND: Because perioperative complications of unrecognized obstructive sleep apnea (OSA) can be severe, many bariatric surgery programs routinely screen all patients. However, many obese non-bariatric surgery patients do not get screened. We wanted to evaluate the need for routine preoperative OSA screening. METHODS: Morbidly obese patients with a body mass index (BMI) > 40 kg/m(2) undergoing bariatric surgery--all screened for OSA--were compared to morbidly obese orthopedic lower extremity total joint replacements (TJR) patients--not screened for OSA. Cardio-pulmonary complications were recorded. RESULTS: Eight hundred eighty-two morbidly obese patients undergoing either bariatric (n = 467) or orthopedic TJR surgery (n = 415) were compared. As a result of screening, 119 bariatric surgery patients (25.5 %) were newly diagnosed with OSA, bringing the incidence to 42.8 % (200/467). Orthopedic surgery group had 72 of 415 (17.3 %) patients with pre-existing OSA. The unscreened orthopedic patients had a 6.7 % (23/343) cardiopulmonary complications rate compared to 2.6 % (7/267) for screened bariatric surgery patients. This difference was not statistically significant when adjusted for age and comorbidity (p = 0.3383). CONCLUSION: Sleep apnea screening prior to bariatric surgery identifies an additional 25 % of patients as having OSA. In this study, unscreened morbidly obese patients did not have an increased incidence of cardiopulmonary complications after surgery compared to screened patients. Prospective randomized studies should be conducted to definitively assess utility and cost effectiveness of routine OSA screening of all morbidly obese patients undergoing surgery. Preoperative OSA screening may be safely omitted when randomizing patients for such a trial.

Radiology of the laparoscopic Roux-en-Y gastric bypass procedure: conceptualization and precise interpretation of results.

Obesity is an epidemic in the United States. The laparoscopic Roux-en-Y gastric bypass procedure is an effective surgical intervention that can produce dramatic weight loss in morbidly obese patients. Despite the inherent risks, the surgery is increasing in popularity. Radiology plays a crucial role in postoperative evaluation. Upper gastrointestinal (UGI) series and abdominal computed tomography (CT) are the primary radiologic tools used in assessment of possible complications. With knowledge of the normal postoperative appearance, performance of UGI studies and interpretation of the results should be easy. The 24-hour postoperative examination allows reliable detection of anastomotic leaks. Although strictures of the gastrojejunal anastomosis are a common complication, they are often diagnosed and treated with endoscopy. In a thorough examination, one also evaluates for degraded pouch restriction, including a patulous gastrojejunal anastomosis or gastrogastric fistula, as a late cause of weight gain. Knowledge of the postoperative anatomy also assists in detection of internal hernias. CT is invaluable in detection and characterization of small bowel obstructions and internal hernias. CT may allow diagnosis of anastomotic leaks, abscesses, gastrogastric fistulas, and intra-abdominal hematomas. CT-guided percutaneous procedures, such as placement of gastrostomy tubes or drainage of fluid collections, can obviate emergency exploration and may be the only procedural intervention necessary for a cure.

Uncinatectomy: a novel surgical option for the management of intraductal papillary mucinous tumors of the pancreas.

An intraductal papillary mucinous tumor (IPMT) is a rare cystic lesion of the pancreas, comprising only 1% of all pancreatic exocrine neoplasms. The prognosis for these lesions is typically favorable as compared with invasive ductal carcinomas. Nevertheless, the management of IPMTs involves surgical resection due to their malignant potential. When located in the pancreatic head, the conventional treatment for IPMT is pancreatoduodenectomy. Some authors have advocated limited pancreatectomy for low-grade IPMTs of the pancreas, thereby decreasing the morbidity of more extensive resection. In this report, we describe our technique of minimal pancreatectomy, whereby the uncinate process and associated branch duct were completely extirpated while preserving remainder of the pancreatic head, duodenum, and pancreatic ducts. The case presented underscores the feasibility and advantages of minimal pancreatic resection in the management of such tumors.

Predicting outcome and directing therapy for papillary thyroid carcinoma.

HYPOTHESIS: The prognosis of papillary thyroid carcinoma has been stratified into low- and high-risk groups. Patients in the high-risk group can be substratified on the basis of increasing age, with implications for prognosis and treatment. DESIGN: Retrospective study. SETTING: Tertiary care center. PATIENTS: A total of 727 patients with papillary thyroid cancer treated at Lahey Clinic, Burlington, Mass, from 1940 to 1998. INTERVENTIONS: Stratification into low- and high-risk groups based on age, metastases, extent, and size. High-risk patients were substratified into "younger" and "older" high-risk groups by age younger than 60 years or 60 years and older, respectively. Effects of surgery, lymph node dissection, and radiation therapy were examined. Main Outcome Measure Survival. RESULTS: Of the 727 patients, 585 (80.5%) were classified as low risk and 142 (19.5%) as high risk. The 20-year survival was 97.8% in low-risk patients and 61.3% in high-risk patients (P<.001); it was 72.3% in the younger high-risk group and 45.1% in the older high-risk group (P<.001). Older high-risk patients had a survival advantage with bilateral thyroidectomy: 54.7% 20-year survival for those undergoing bilateral thyroidectomy and 25.0% for unilateral thyroidectomy (P =.004). In the older high-risk group, patients with lymph node dissection (n = 22) had a 20-year survival of 72.4% vs 30.2% in patients who did not undergo lymph node dissection (n = 38) (P =.03). Twenty-year survival in low-risk, younger high-risk, and older high-risk patients receiving radioactive iodine vs no radiation was 100% vs 97.6% (P =.24), 64.2% vs 73.2% (P =.53), and 44.7% vs 44.4% (P =.53). CONCLUSIONS: Papillary thyroid carcinoma in low-risk patients had a favorable prognosis regardless of treatment. Older high-risk patients had a survival benefit with total thyroidectomy and lymph node dissection. Radioactive iodine did not affect 20-year survival in any of the risk groups.